The Nexus of Suicide and Misusing Opioids and Benzodiazepines

February 14, 2019

In March 2018, The New York Times published a long-form article about what reporter Paula Span called “a quiet drug problem among the elderly”: the widespread misuse of benzodiazepines among older Americans. “For years, geriatricians and researchers have sounded the alarm about the use of benzodiazepines among older adults. Often called “benzos,” the problem drugs include Valium (diazepam), Klonopin (clonazepam), Xanax (alprazolam) and Ativan (lorazepam).”

“At first, the pills helped her feel so much better,” Span wrote about an artist living in Manhattan, who had been diagnosed with an anxiety disorder that led to panic attacks, a racing pulse, and sleeplessness. But then she developed tolerance and her doctors keep increasing the dosage and added other benzos. The drugs turned on her, remembers the 67-year-old in the Times story.

The opioid crisis ravaging America has added another threat level, because opioid pain relievers like Vicodin and OxyContin are also frequently prescribed for older people. When patients take both, they face an elevated risk of overdosing—especially when they are exceeding the prescribed dosage or are acquiring the medications from different physicians who are unaware of the “doctor shopping.”

The Suicide Link

Misusing both benzos and opioid is also correlated with increased thoughts of suicide, according to a new study published in the International Journal of Geriatric Psychiatry. The study’s authors looked at data for more than 17,000 adults ages 50 and older and found that the rate of past-year suicidal ideation was 25.4 percent in individuals reporting misuse of both prescription opioids and benzodiazepines. By comparison, the past-year rate of suicidal ideation was only 2.2 percent among older adults who were not misusing either prescription opioids or benzodiazepines.

Researchers Ty Schepis, Linda Simoni‐Wastila, and Sean Esteban McCabe concluded that “both past‐year prescription opioid and benzodiazepine misuse are associated with past‐year suicidal ideation in US older adults” and recommend that “clinicians encountering older adult patients at‐risk for or engaged in prescription medication misuse also should screen for suicidality.”

The question is, are those patients suicidal as a result of the drug misuse or are they trying to alleviate a severe depression with illicit drug use? In other words, is the drug abuse a symptom of a depression with suicidal ideation rather than its cause?

Schepis et al. found that past‐year use without misuse of prescription opioids or benzodiazepines was not associated with past‐year suicidal ideation in older adults. Other studies, however, have linked the prescribed use of benzodiazepines alone to “an overall increase in the risk of attempting or completing suicide.”

Deaths of Despair

Depression, anxiety, excessive stress and trauma are significant risk factors for substance use disorders. Many depressed people are also socially isolated and attempt to self-medicate their emotional pain with drugs and alcohol.

Loneliness and disconnection are increasingly on the radar of behavioral health experts. In his new book Lost Connections, addiction expert Johann Hari identified nine “disconnection” causes for depression and anxiety disorders. One of the nine is being disconnected from other people: “We do things together less than any humans who came before us,” writes Hari.

In 2015, two Princeton economists argued that middle-aged white Americans without a college degree were now facing “deaths of despair”—suicide, overdoses from drugs and alcohol, and alcohol-related liver disease. Distress born of globalization and rapid technological change probably drove the deadly outcome, the research by Anne Case and Nobel Prize winner Angus Deaton suggests. Middle-aged whites are now more likely than their predecessors to report pain and mental-health problems and are experiencing symptoms of alcoholism at a younger age.

Declining Life Expectancy

Americans are dying at a faster rate, and they’re dying younger. The suicide death rate last year was the highest in half a century, according to data provided by the Centers for Disease Control and Prevention (CDC). There were more than 47,000 suicides, up from a little under 45,000 the year before. For decades, life expectancy in the United States was increasing by a few months nearly every year. Now it’s trending the other way: It fell in 2015, stayed level in 2016, and declined again last year, the CDC said.

The nation is currently experiencing the longest period of declining life expectancy since the late 1910s, when World War I and the worst flu pandemic in modern history combined to kill nearly one million Americans. Life expectancy in 1918 was 39.

People who misuse opioids and benzodiazepines to “feel better” may need therapy that addresses the underlying reasons for their substance use disorder. They need comprehensive treatment that deals with the substance use and any co-occurring mental health problems to be effective. Otherwise, they face an increased risk of overdose and suicide.